| FIG. 17. |
| Completed Reposition of the Retroverted or Retroflexed Uterus by Conjoined Manipulation (modified from Schultze). |
The replacement is not usually accomplished by drawing the fundus forward and pushing the cervix back directly in the median line. In most cases the fundus sweeps around the arc of a circle on the left side of the pelvis, and the cervix on the right. This is owing to the greater frequency of cellulitis on the left side, and consequent shortening of the left broad ligament. After replacement the organ is to be held in position by a suitable pessary.
Bimanual replacement has two great advantages over the more familiar methods of the sound or repositor: first, it is more effective and more permanent; second, the lever action of the sound or repositor, by which the operator may unwittingly use an undue and dangerous amount of force, is avoided in the use of the hands, through which the operation is not only constantly under his control, but also within his appreciation.
Inasmuch as the pessary fulfils its indications by sustaining the pelvic floor, and thereby holding the cervix in the hollow of the sacrum, the same general principles, and in fact the same pessaries, which are applicable to prolapse apply also to retroversion and retroflexion. Indeed, the first step in the genesis of the retro-positions has been shown to be prolapse. The student is therefore referred to the general remarks on the adjustment of pessaries for prolapse.
The operations of elytrorraphy and perineorraphy, especially the latter, already described in the treatment of descent, are often of the utmost importance in the treatment of the posterior displacements, and should therefore be carefully studied in this connection.
In the adjustment of the pessary it is desirable, if possible, to avoid direct pressure upon any part of the uterus. Pessaries designed to prop up the body of the uterus by pressure upon the posterior wall to correct the posterior malpositions, and upon the anterior wall to correct the anterior malpositions, are very liable to induce metritis and perimetritis, and are therefore generally unsafe. In certain cases, however, the vaginal walls, especially the posterior, may be so relaxed from subinvolution and other causes that the instrument, though very long, fails to maintain the cervix in its normal place. Under such conditions a pessary may be required to act directly upon the uterus. The Schultze's sleigh pessary represented in Fig. 19 fulfils this indication. Schultze's figure-of-eight pessary, or a long Albert Smith pessary with its uterine curve made so extreme as to bring the upper part of the instrument in front of the cervix instead of behind, answers the same purpose.
| FIG. 18. |
| Showing the Pelvic Organs sustained by the Emmet Pessary alter reposition of the prolapsed, retroverted or retroflexed uterus. |
Thomas's retroflexion pessary, with its bulbous upper extremity, is a long narrow instrument of extreme uterine curve. It lifts the uterus very high, and is specially applicable in cases of great relaxation of the pelvic floor and of complicating prolapse of the ovaries (Fig. 21). The bulbous portion is sometimes made of soft rubber.